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[Printable PDF Version]
INDIANA SURGICAL SPECIALISTS, L.L.C.
NOTICE OF PRIVACY
PRACTICES
Effective: April 14,
2003
THIS NOTICE DESCRIBES
HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
This notice will tell you how we may use
and disclose protected health information about you. Protected health
information means any health information about you that identifies you
or for which there is a reasonable basis to believe the information can
be used to identify you. In this notice, we call all of that protected
health information, “medical information.”
This notice also will tell you about your rights and our duties with
respect to medical information about you. In addition, it will tell you
how to complain to us if you believe we have violated your privacy
rights.
Who Is Bound By This Notice?
This Notice of Privacy Practices describes the practices of Indiana
Surgical Specialists, L.L.C.
This notice applies all of the medical offices and clinics belonging to
or leased to Indiana Surgical Specialists.
We all will follow what is said in this Notice.
How We May Use and Disclose Medical Information About You.
We will share medical information about you with each other as necessary
to carry out treatment, payment, or our health care operations.
We use and disclose medical information about you for a number of
different purposes. Each of those purposes is described below.
For Treatment.
We may use medical information about you to provide, coordinate or
manage your health care and related services by both us and other health
care providers. We may disclose medical information about you to
doctors, nurses, hospitals and other health facilities who become
involve in your care. We may consult with other health care providers
concerning you and as part of the consultation share your medical
information with them. Similarly, we may refer you to another health
care provider and as part of the referral share medical information
about you with that provider. For example, we may conclude you need to
receive services from a physician with a particular specialty. When we
refer you to that physician, we also will contact that physician’s
office and provide medical information about you to them so they have
information they need to provide services for you.
For Payment.
We may use and disclose medical information about you so we can be paid
for the services we provide to you. This can include billing you, your
insurance company, or a third party payor. For example, we may need to
give your insurance company information about the health care services
we provide to you so your insurance company will pay us for those
services or reimburse you for amounts you have paid. We also may need to
provide your insurance company or a government program, such as Medicare
or Medicaid, with information about your medical condition and the
health care you need to determine if you are covered by that insurance
or program.
For Health Care Operations.
We may use and disclose medical information about you for our own health
care operations. These are necessary for us to operate ISS and to
maintain quality health care for our patients. For example, we may use
medical information about you to review the services we provide and the
performance of our employees in caring for you. We may disclose medical
information about you to train our staff and students working in ISS. We
also may use the information to study ways to more efficiently manage
our organization.
How We Will Contact You.
Unless you tell us otherwise in writing, we may contact you by either
telephone or by mail at either your home or your office. At either
location, we may leave messages for you on the answering machine or
voice mail. If you want to request that we communicate to you in a
certain way or at a certain location, see “Right to Receive Confidential
Communications”.
Appointment Reminders.
We may use and disclose medical information about you to contact you to
remind you of an appointment you have with us.
Treatment Alternatives.
We may use and disclose medical information about you to contact you
about treatment alternatives that may be of interest to you.
Health Related Benefits and Services.
We may use and disclose medical information about you to contact you
about health-related benefits and services that may be of interest to
you.
Individuals Involved in Your Care.
We may disclose to a family member, other relative, a close personal
friend, or any other person identified by you, medical information about
you that is directly relevant to that person’s involvement with your
care or payment related to your care. We also may use or disclose
medical information about you to notify, or assist in notifying, those
persons of your location, general condition, or death. If there is a
family member, other relative, or close personal friend that you do not
want us to disclose medical information about you to, please notify
PRIVACY OFFICER or tell our staff member who is providing care to you.
Disaster Relief.
We may use or disclose medical information about you to a public or
private entity authorized by law or by its charter to assist in disaster
relief efforts. This will be done to coordinate with those entities in
notifying a family member, other relative, close personal friend, or
other person identified by you of your location, general condition or
death.
Required by Law.
We may use or disclose medical information about you when we are
required to do so by law.
Public Health Activities.
We may disclose medical information about you for public health
activities and purposes. This includes reporting medical information to
a public health authority that is authorized by law to collect or
receive the information for purposes of preventing or controlling
disease. Or, one that is authorized to receive reports of child abuse
and neglect.
Victims of Abuse, Neglect or Domestic Violence.
We may disclose medical information about you to a government authority
authorized by law to receive reports of abuse, neglect, or domestic
violence, if we believe you are a victim of abuse, neglect, or domestic
violence. This will occur to the extent the disclosure is: (a) required
by law; (b) agreed to by you; or, (c) authorized by law and we believe
the disclosure is necessary to prevent serious harm to you or to other
potential victims, or, if you are incapacitated and certain other
conditions are met, a law enforcement or other public official
represents that immediate enforcement activity depends on the
disclosure.
Health Oversight Activities.
We may disclose medical information about you to a health oversight
agency for activities authorized by law, including audits,
investigations, inspections, licensure or disciplinary actions. These
and similar types of activities are necessary for appropriate oversight
of the health care system, government benefit programs, and entities
subject to various government regulations.
Judicial and Administrative Proceedings.
We may disclose medical information about you in the course of any
judicial or administrative proceeding in response to an order of the
court or administrative tribunal. We also may disclose medical
information about you in response to a subpoena, discovery request, or
other legal process but only if efforts have been made to tell you about
the request or to obtain an order protecting the information to be
disclosed.
Disclosures for Law Enforcement Purposes.
We may disclose medical information about you to a law enforcement
official for law enforcement purposes:
- As required by law.
- In response to a court, grand jury
or administrative order, warrant or subpoena.
- To identify or locate a suspect,
fugitive, material witness or missing person.
- About an actual or suspected victim
of a crime and that person agrees to the disclosure. If we are
unable to obtain that person’s agreement, in limited circumstances,
the information may still be disclosed.
- To alert law enforcement officials
to a death if we suspect the death may have resulted from criminal
conduct.
- About crimes that occur at our
facility.
- To report a crime in emergency
circumstances.
Coroners and Medical Examiners.
We may disclose medical information about you to a coroner or medical
examiner for purposes such as identifying a deceased person and
determining cause of death.
Funeral Directors.
We may disclose medical information about you to funeral directors as
necessary for them to carry out their duties.
Organ, Eye or Tissue Donation.
To facilitate organ, eye or tissue donation and transplantation, we may
disclose medical information about you to organ procurement
organizations or other entities engaged in the procurement, banking or
transplantation of organs, eyes or tissue.
Research.
Under certain circumstances, we may use or disclose medical information
about you for research. Before we disclose medical information for
research, the research will have been approved through an approval
process that evaluates the needs of the research project with your needs
for privacy of your medical information. We may, however, disclose
medical information about you to a person who is preparing to conduct
research to permit them to prepare for the project, but no medical
information will leave ISS during that person’s review of the
information.
To Avert Serious Threat to Health or Safety.
We may use or disclose protected health information about you if we
believe the use or disclosure is necessary to prevent or lessen a
serious or imminent threat to the health or safety of a person or the
public. We also may release information about you if we believe the
disclosure is necessary for law enforcement authorities to identify or
apprehend an individual who admitted participation in a violent crime or
who is an escapee from a correctional institution or from lawful
custody.
Military.
If you are a member of the Armed Forces, we may use and disclose medical
information about you for activities deemed necessary by the appropriate
military command authorities to assure the proper execution of the
military mission. We may also release information about foreign military
personnel to the appropriate foreign military authority for the same
purposes.
National Security and Intelligence.
We may disclose medical information about you to authorized federal
officials for the conduct of intelligence, counter-intelligence, and
other national security activities authorized by law.
Protective Services for the President.
We may disclose medical information about you to authorized federal
officials so they can provide protection to the President of the United
States, certain other federal officials, or foreign heads of state.
Security Clearances.
We may use medical information about you to make medical suitability
determinations and may disclose the results to officials in the United
States Department of State for purposes of a required security clearance
or service abroad.
Inmates; Persons in Custody.
We may disclose medical information about you to a correctional
institution or law enforcement official having custody of you. The
disclosure will be made if the disclosure is necessary: (a) to provide
health care to you; (b) for the health and safety of others; or, (c) the
safety, security and good order of the correctional institution.
Workers Compensation.
We may disclose medical information about you to the extent necessary to
comply with workers’ compensation and similar laws that provide benefits
for work-related injuries or illness without regard to fault.
Other Uses and Disclosures.
Other uses and disclosures will be made only with your written
authorization. You may revoke such an authorization at any time by
notifying The Privacy Officer for ISS in writing of your desire to
revoke it. However, if you revoke such an authorization, it will not
have any affect on actions taken by us in reliance on it.
Your Rights With Respect to Medical Information About You.
You have the following rights with respect to medical information that
we maintain about you.
Right to Request Restrictions.
You have the right to request that we restrict the uses or disclosures
of medical information about you to carry out treatment, payment, or
health care operations. You also have the right to request that we
restrict the uses or disclosures we make to: (a) a family member, other
relative, a close personal friend or any other person identified by you;
or, (b) for to public or private entities for disaster relief efforts.
For example, you could ask that we not disclose medical information
about you to your brother or sister.
To request a restriction, you may do so at the time you complete your
consent form or at any time after that time. If you request a
restriction after that time, you should do so in writing to The Privacy
Officer for ISS, 7900 W. Jefferson, Blvd. Ste. 304, Fort Wayne, IN.,
46804 and tell us: (a) what information you want to limit; (b) whether
you want to limit use or disclosure or both; and, (c) to whom you want
the limits to apply (for example, disclosures to your spouse).
We are not required to agree to any requested restriction.
However, if we do agree, we will follow that restriction unless the
information is needed to provide emergency treatment. Even if we agree
to a restriction, either you or we can later terminate the restriction.
Right to Receive Confidential Communications.
You have the right to request that we communicate medical information
about you to you in a certain way or at a certain location. For example,
you can ask that we only contact you by mail or at work. We will not
require you to tell us why you are asking for the confidential
communication.
If you want to request confidential communication, you must do so in
writing to The Privacy Officer, Indiana Surgical Specialists, 7900 W.
Jefferson Blvd., Fort Wayne, IN., 46804 . Your request must state how or
where you can be contacted.
We will accommodate your request. However, we may, when appropriate,
require information from you concerning how payment will be handled.
Right to Inspect and Copy.
With a few very limited exceptions, such as psychotherapy notes, you
have the right to inspect and obtain a copy of medical information about
you.
To inspect or copy medical information about you, you must submit your
request in writing to Medical Records, Indiana Surgical Specialists,
7900 W. Jefferson Blvd., Ste. 304, Fort Wayne, IN., 46804 . Your request
should state specifically what medical information you want to inspect
or copy. If you request a copy of the information, we may charge a fee
for the costs of copying and, if you ask that it be mailed to you, the
cost of mailing.
We will act on your request within thirty (30) calendar days after we
receive your request. If we grant your request, in whole or in part, we
will inform you of our acceptance of your request and provide access and
copying.
We may deny your request to inspect and copy medical information if the
medical information involved is:
- Psychotherapy notes;
- Information compiled in anticipation
of, or use in, a civil, criminal or administrative action or
proceeding;
If we deny your request, we will inform
you of the basis for the denial, how you may have our denial reviewed,
and how you may complain. If you request a review of our denial, it will
conducted by a licensed health care professional designed by us who was
not directly involved in the denial. We will comply with the outcome of
that review.
Right to Amend.
You have the right to ask us to amend medical information about you. You
have this right for so long as the medical information is maintained by
us.
To request an amendment, you must submit your request in writing to
Privacy Officer, Indiana Surgical Specialists, 7900 W. Jefferson Blvd.,
Ste. 304, Fort Wayne, IN., 46804 . Your request must state the amendment
desired and provide a reason in support of that amendment.
We will act on your request within sixty (60) calendar days after we
receive your request. If we grant your request, in whole or in part, we
will inform you of our acceptance of your request and provide access and
copying.
If we grant the request, in whole or in part, we will seek your
identification of and agreement to share the amendment with relevant
other persons. We also will make the appropriate amendment to the
medical information by appending or otherwise providing a link to the
amendment.
We may deny your request to amend medical information about you. We may
deny your request if it is not in writing and does not provide areason
in support of the amendment. In addition, we may deny your request to
amend medical information if we determine that the information:
- Was not created by us, unless the
person or entity that created the information is no longer available
to act on the requested amendment;
- Is not part of the medical
information maintained by us;
- Would not be available for you to
inspect or copy; or,
- Is accurate and complete.
If we deny your request, we will inform
you of the basis for the denial. You will have the right to submit a
statement of disagreeing with our denial. Your statement may not exceed
2 pages. We may prepare a rebuttal to that statement. Your request for
amendment, our denial of the request, your statement of disagreement, if
any, and our rebuttal, if any, will then be appended to the medical
information involved or otherwise linked to it. All of that will then be
included with any subsequent disclosure of the information, or, at our
election, we may include a summary of any of that information.
If you do not submit a statement of disagreement, you may ask that we
include your request for amendment and our denial with any future
disclosures of the information. We will include your request for
amendment and our denial (or a summary of that information) with any
subsequent disclosure of the medical information involved.
You also will have the right to complain about our denial of your
request.
Right to an Accounting of Disclosures.
You have the right to receive an accounting of disclosures of medical
information about you. The accounting may be for up to six (6) years
prior to the date on which you request the accounting but not before
April 14, 2003.
Certain types of disclosures are not included in such an accounting:
- Disclosures to carry out treatment,
payment and health care operations;
- Disclosures of your medical
information made to you;
- Disclosures for our facility
directory;
- Disclosures for national security or
intelligence purposes;
- Disclosures to correctional
institutions or law enforcement officials;
- Disclosures made prior to April 14,
2003.
Under certain circumstances your right to
an accounting of disclosures may be suspended for disclosures to a
health oversight agency or law enforcement official.
To request an accounting of disclosures, you must submit your request in
writing to Privacy Officer, Indiana Surgical Specialists, 7900 W.
Jefferson Blvd., Suite 304, Fort Wayne, IN., 46804 . Your request must
state a time period for the disclosures. It may not be longer than six
(6) years from the date we receive your request and my not include dates
before April 14, 2003.
Usually, we will act on your request within sixty (60) calendar days
after we receive your request. Within that time, we will either provide
the accounting of disclosures to you or give you a written statement of
when we will provide the accounting and why the delay is necessary.
There is no charge for the first accounting we provide to you in any
twelve (12) month period. For additional accountings, we may charge you
for the cost of providing the list. If there will be a charge, we will
notify you of the cost involved and give you an opportunity to withdraw
or modify your request to avoid or reduce the fee.
Right to Copy of this Notice.
You have the right to obtain a paper copy of our Notice of Privacy
Practices. You may obtain a paper copy even though you agreed to receive
the notice electronically. You may request a copy of our Notice of
Privacy Practices at any time.
You may obtain a copy of our Notice of Privacy Practices over the
Internet at our web site,
www.indianasurgicalspecialists.com.
To obtain a paper copy of this notice, contact to Privacy Officer,
Indiana Surgical Specialists, 7900 W. Jefferson Blvd., Suite 304, Fort
Wayne, IN. 46804 .
Our Duties
Generally.
We are required by law to maintain the privacy of medical information
about you and to provide individuals with notice of our legal duties and
privacy practices with respect to medical information.
We are required to abide by the terms of our Notice of Privacy Practices
in effect at the time.
Our Right to Change Notice of Privacy Practices.
We reserve the right to change this Notice of Privacy Practices. We
reserve the right to make the new notice’s provisions effective for all
medical information that we maintain, including that created or received
by us prior to the effective date of the new notice.
Availability of Notice of Privacy Practices.
A copy of our current Notice of Privacy Practices will be posted STATE
OF INDIANA. A copy of the current notice also will be posted on our web
site,
www.indiansurgicalspecialists.com. In addition, each time you are
admitted to services at ISS, a copy of the current notice will be made
available to you.
At any time, you may obtain a copy of the current Notice of Privacy
Practices by contacting to Indiana Surgical Specialists, L.L.C. at (260)
436-0058 or toll free 1-800-633-5331.
Effective Date of Notice.
The effective date of the notice will be stated on the first page of the
notice.
Complaints.
You may complain to us and to the United States Secretary of Health and
Human Services if you believe your privacy rights have been violated by
us.
To file a complaint with us, contact Indiana Surgical Specialists, Att:
Privacy Officer, 7900 W. Jefferson Blvd., Ste. 304, Fort Wayne, IN.,
46804. All complaints should be submitted in writing.
To file a complaint with the United States Secretary of Health and Human
Services, send your complaint to him or her in care of: Office for Civil
Rights, U.S. Department of Health and Human Services, 200 Independence
Avenue SW, Washington, D.C. 20201.
You will not be retaliated against for filing a complaint.
Questions and Information.
If you have any questions or want more information concerning this
Notice of Privacy Practices, please contact PRIVACY OFFICER, Indiana
Surgical Specialists, 7900 W. Jefferson Blvd., Suite 304, Fort Wayne,
IN., 46804 (260) 436-0058 x 3207. |
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